Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population

Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations

Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.

Comparative study on treatment of acute cerebral infarction between mechanical thrombectomy by micro catheter and thrombectomy by Solitaire AB stent

BACKGROUND

Acute cerebral artery occlusion is a common disease with high morbidity and mortality. At present, the commonly used mechanical thrombectomy schemes are mechanical thrombectomy and stent thrombectomy. However, the clinical differences between the two methods is not fully understood. The present study aimed to evaluate the clinical effectiveness of Solitaire AB stent thrombectomy for acute cerebral infarction (ACI).

METHODS

A retrospective study was carried out in 96 ACI patients admitted to our department from January 2017 to January 2020. According to the treatment they received, they were divided into group A (conventional microcatheter mechanical thrombectomy, n = 48) and group B (Solitaire AB stent thrombectomy, n = 48). All patients were followed up for 3 months. Their pre- and post-operative nerve function indices were compared between the 2 groups. The therapeutic effects were evaluated by thrombolysis in cerebral infarction scale system, Glasgow coma scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin scale statistics.

RESULTS

Two groups of patients with NIHSS scores postoperative 3 and 30 days decreased significantly compared with preoperation. NIHSS score of group A 3 and 30 days postoperation was significantly higher than group B (P < .05). Two groups of patients with GCS scores postoperative 3 and 30 days increased significantly compared with preoperation. GCS score of group A 3 and 30 days postoperation was significantly lower than group B (P < .05). Group B with vascular recanalization ratio postoperative 30 days was higher than group A, however with no significant differences (P > .05). Moreover, group B with outcomes (modified Rankin scale score ≤2 points) postoperative 3 months was better than group A, however with no significant differences (P > .05).

CONCLUSION

Solitaire AB stent embolectomy shows similar efficacy as mechanical thrombectomy in the treatment of ACI patients.

Extended Time Window Mechanical Thrombectomy for Acute Stroke in Brazil

BACKGROUND

Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) caused by large vessel occlusion of the anterior circulation within 6 hours of symptoms onset and can be performed with an extended window up to 24 hours in selected patients. Nevertheless, the outcomes of MT with extended window are unknown in developing countries.

OBJECTIVE

Explore the safety and efficacy of MT for AIS performed beyond 6 hours from symptoms onset in Brazil.

METHODS

We reviewed data from AIS patients treated with MT beyond 6 hours of stroke onset, from 2015 to 2018 in a Brazilian public hospital. Patients had an occlusion of the intracranial internal carotid artery and/or proximal segment of the middle cerebral artery. CT Perfusion mismatch was evaluated using the RAPID® software. We evaluated the modified Rankin scale (mRS) and mortality at 90 days, and rate of symptomatic intracranial hemorrhage (sICH).

RESULTS

Fifty-four patients were included, with a mean age of 65.6 ± 16.1 years, 55.6% were male, and the median NIHSS score at presentation was 17. Successful recanalization (TICI 2b to 3) was obtained in 92.6% of patients and sICH rate was 11.1%. Overall, 34% of the patients had a good outcome (mRS ≤2) at 90 days and the mortality rate was 20.3%.

CONCLUSION

Our study, the first series of MT for AIS treated with extended window reported in Latin America, shows that MT can be performed with safety and lead to adequate functional outcomes in this context. Further studies should explore the barriers to broad implementation of MT for AIS in Latin America.

Solitaire Stent in the Treatment of Acute Ischemic Stroke with Large Cerebral Artery Occlusion

Objective

To investigate the effect of mechanical thrombectomy with solitaire stent in the treatment of acute ischemic stroke with large cerebral artery occlusion.

Methods

Fifteen acute ischemic stroke patients with a proximal intracranial occlusion in the anterior circulation were included within 6 hours after symptom onset (unknown time of onset allowed in wake upstroke). Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. All patients were measured by the National Institutes of Health Stroke Scale (NIHSS) before and 24 hours after the procedure. The primary outcomes were reperfusion at 24 hours and a Thrombolysis in Cerebral Infarction (TICI) score of 2b or 3 indicates successful reperfusion. Secondary outcomes included the functional score on the Modified Rankin Scale(MRS) and NIHSS score at 90 days. Good Functional Outcome (GFO), is defined as mRS0–2 at 90 days.

Results

The preoperative TICI grading of these 15 patients were all level 0.14 patients were level 2b to level 3 after the thrombectomy, 1 ipsilateral cervical carotid occlusion patient failed recanalization.14 patients with reperfusion at 24 hours showed good early neurologic improvement. The MRS score of all the 14 patients were<2 point at 90 days. There were no obvious adverse reactions and complications in these patients after mechanical thrombectomy.

Conclusion

The application of mechanical thrombectomy with solitaire stent for the treatment of acute ischemic stroke with large cerebral artery occlusion is safe and time-efficient, which could improve the recanalization rate, decrease or even eliminate the application of thrombolytic drugs and reduce the rate of intracranial hemorrhage. Awake stroke patient can also benefit from thrombectomy.

Clinical Outcomes of Patients with Acute Basilar Artery Occlusion in Brazil: An Observational Study

BACKGROUND

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) were proven safe and effective for anterior circulation proximal occlusions. However, the most appropriate recanalization strategy in patients with acute basilar artery occlusion (BAO) is still controversial. This study aimed to assess outcomes of patients with BAO at an academic stroke center in Brazil.

METHODS

This is a retrospective analysis of consecutive patients with BAO from a prospective stroke registry at Ribeirão Preto Medical School. Primary outcomes were mortality and favorable outcome (modified Rankin score [mRS] ≤3) at 90 days. After univariate analyses, multivariate logistic regressions were used to identify independent predictors of primary outcomes.

RESULTS

Between August 2004 and December 2015, 63 (65% male) patients with BAO and median National Institutes of Health Stroke Scale (NIHSS) score of 31 (interquartile range: 19-36) were identified. Twenty-nine (46%) patients received no acute recanalization therapy, 15 (24%) received IVT, and 19 (30%) received EVT (68% treated with stent retrievers). Twenty-four (83%) patients treated conservatively died, and only 2 (7%) achieved an mRS less than or equal to 3. Among patients treated with acute recanalization therapies, 15 (44%) died, and 9 (26.5%) had a favorable outcome. On multivariate analysis, baseline systolic blood pressure (odds ratio [OR] = .97; 95% confidence interval [CI]: .95-0.99; P = .023), posterior circulation Alberta Stroke Program Early CT score (OR = .62; 95% CI: .41-0.94; P = .026), and successful recanalization (OR = .18; 95% CI: .04-0.71; P = .015) were independent predictors of lower mortality. Baseline NIHSS (OR = 1.40; 95% CI: 1.08-1.82; P = .012), prior use of statins (OR = .003; 95% CI: .001-0.28; P = .012), and successful recanalization (OR = .05; 95% CI: .001-0.27; P = .009) were independent predictors of favorable outcome. There was no significant difference between the IVT group and the EVT group on primary outcomes.

CONCLUSIONS

BAO is associated with high morbidity and mortality in Brazil. Access to acute recanalization therapies may decrease mortality in those patients.

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke

ABSTRACT These guidelines are the result of a joint effort from writing groups of the Brazilian Stroke Society, the Scientific Department of Cerebrovascular Diseases of the Brazilian Academy of Neurology, the Brazilian Stroke Network and the Brazilian Society of Diagnostic and Therapeutic Neuroradiology. Members from these groups participated in web-based discussion forums with predefined themes, followed by videoconference meetings in which controversies and position statements were discussed, leading to a consensus. This guidelines focuses on the implications of the recent clinical trials on endovascular therapy for acute ischemic stroke due to proximal arterial occlusions, and the final text aims to guide health care providers, health care managers and public health authorities in managing patients with this condition in Brazil.

Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke

ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.

Endovascular treatment of acute ischemic stroke - own experience

OBJECTIVE

Presentation of the own experience in the treatment of ischemic stroke using endovascular methods of simultaneous evaluation of their effectiveness and safety.

MATERIALS AND METHODS

The retrospective study involved a group of 18 patients hospitalized in 2005-2012 who were treated with intraarterial thrombolysis and mechanical thrombectomy. Overall there were 24 procedures performed. The investigated group consisted of seven (38.89%) women and 11 (61.11%) men. The average age of the patients was 60 years (SD ± 17, median - 60 years).

RESULTS

In 62.50% of cases (n=15) the effect of revascularization has been achieved and another 12.50% of cases (n=3) recanalization was achieved only partially. Only in 25% of procedures (n=6) failed to achieve recanalization of the artery (TICI ≤ 1). The highest percentage of recanalized arteries were obtained by following the procedure of thrombolysis targeted - 69.24% (TICI ≥ 2b). In the case of mechanical thrombectomy total patency (TICI ≥ 2b) was 54.55%. The average duration of treatment (operation) is 157 min. After 30 days successful result of the neurological status was achieved in 57.14% of patients (n=8). Full return to independent functioning as defined within 3 months after the surgery (mRS ≤ 2) reached 57.14% of patients (n=8).

CONCLUSION

Studies suggest that endovascular techniques are effective and safe in the treatment of ischemic stroke. Greater efficiency is characterized by intraarterial thrombolysis. Patients who were treated endovascular improved significantly.

Recanalization and Reperfusion Therapies of Acute Ischemic Stroke: What have We Learned, What are the Major Research Questions, and Where are We Headed?

Two placebo-controlled trials have shown that early administration of intravenous recombinant tissue plasminogen activator (rt-PA) after ischemic stroke improves outcomes up to 4.5 h after symptoms onset; however, six other trials contradict these results. We also know from analysis of the pooled data that benefits from treatment decrease as time from stroke onset to start of treatment increases. In addition to time, another important factor is patient selection through multimodal imaging, combining data from artery status, and salvageable tissue measures. Nonetheless, at the present time randomized controlled trials (RCTs) cannot demonstrate any beneficial outcomes for neuroimaging mismatch selection after 4.5 h from symptoms onset. By focusing on cases of large arterial occlusion, we know that recanalization is crucial, so endovascular treatment is an approach of interest. The use of intra-arterial thrombolysis was tested in two small RCTs that demonstrated clear benefits in terms of higher recanalization and also in clinical outcomes. But a new paradigm of stroke treatment may have begun with mechanical thrombectomy. In this field, Merci devices have been overtaken by fully deployed closed-cell self-expanding stents (stent-retrievers or “stent-trievers”). However, despite the high rate of recanalization achieved with stent-retrievers compared with other recanalization treatments, the use of these devices cannot clearly demonstrate better outcomes. Thus, futile recanalization occurs when successful recanalization fails to improve functional outcome. Recently, three RCTs, namely synthesis, IMS-III, and MR-rescue, have not been demonstrated any clear benefit for endovascular treatment. Most likely, these trials were not adequately designed to prove the superiority of endovascular treatment because they did not use optimal target populations, vascular status was not evaluated in all patients, relatively high rates of patients did not have enough mismatch, time from baseline neuroimaging to recanalization were too long or the devices used are now obsolete relative to stent-retrievers. Several RCTs currently underway are trying to determine whether bridging therapy is more effective than intravenous treatment and if mechanical thrombectomy is more effective than best medical treatment in patients ineligible for intravenous thrombolysis.

Neurothrombectomy in the treatment of acute ischaemic stroke

Major ischaemic stroke is a leading cause of morbidity and mortality in industrialized countries. For patients with acute stroke, fast and effective vessel recanalization is important for successful treatment. Neurothrombectomy--that is, angiographically performed mechanical thrombus removal from intracranial arteries--results in higher recanalization rates than with pharmaceutical thrombolysis alone, but the value of this treatment in terms of clinical outcome remains to be established. This article summarizes the history of intra-arterial stroke treatment, outlines the recent developments and the different techniques used, and discusses the results of current studies on neurothrombectomy. Owing to the high morphological and clinical variability of stroke, careful patient selection in future randomized controlled trials will be crucial for assessment of the true potential of neurothrombectomy.